community health program · 2018-06-05 · victorian auditor‐general’s report community health...

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Victorian Auditor -General’s Office

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unity Health Program

2017–18: 21June 2018

Independent assurance report to Parliament2017–18: 21

Community Health Program

June 2018

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Community Health Program

Independent assurance report to Parliament

Ordered to be published

VICTORIAN GOVERNMENT PRINTER

June 2018

PP no 397, Session 2014–18

This report is printed on Monza Recycled paper. Monza Recycled is certified Carbon Neutral by The Carbon Reduction Institute

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The Hon Bruce Atkinson MLC The Hon Colin Brooks MP

President Speaker

Legislative Council Legislative Assembly

Parliament House Parliament House

Melbourne Melbourne

Dear Presiding Officers

Under the provisions of section 16AB of the Audit Act 1994, I transmit my report

Community Health Program.

Yours faithfully

Andrew Greaves

Auditor-General

6 June 2018

Victorian Auditor‐General’s Report Community Health Program 5

Contents

Audit overview ............................................................................................................. 7

Conclusion ......................................................................................................................................... 8 Findings .............................................................................................................................................. 8 Recommendations ........................................................................................................................... 11 Responses to recommendations ..................................................................................................... 11

1 Audit context ......................................................................................................... 13

1.1 Community health services .................................................................................................... 13 1.2 The Community Health Program ............................................................................................ 16 1.3 Department of Health and Human Services ........................................................................... 18 1.4 Service delivery ....................................................................................................................... 18 1.5 Program funding ..................................................................................................................... 19 1.6 Why this audit is important .................................................................................................... 19 1.7 What this audit examined and how ....................................................................................... 19 1.8 Report structure ..................................................................................................................... 20

2 Strategic management .......................................................................................... 21

2.1 Conclusion .............................................................................................................................. 21 2.2 Long‐term health strategies ................................................................................................... 22 2.3 Evidence base for the CHP ...................................................................................................... 23 2.4 Funding for the CHP ................................................................................................................ 25

3 Access and demand ............................................................................................... 29

3.1 Conclusion .............................................................................................................................. 29 3.2 Guidance for access and demand ........................................................................................... 29 3.3 Administering the demand management framework ............................................................ 31 3.4 Demand in community health services .................................................................................. 34

4 Performance and quality ....................................................................................... 39

4.1 Conclusion .............................................................................................................................. 39 4.2 DHHS’s performance management system ............................................................................ 40 4.3 State‐level performance management ................................................................................... 41 4.4 Action taken to address the gaps in current performance measures .................................... 43 4.5 Agency‐level performance management across the sector ................................................... 44 4.6 The Divisional Performance Assurance and Compliance process .......................................... 53 4.7 Data reporting for performance management ....................................................................... 53 4.8 High‐quality service delivery .................................................................................................. 55

Appendix A. Audit Act 1994 section 16—submissions and comments ..................... 61

6 Community Health Program Victorian Auditor‐General’s Report

Acronyms and abbreviations

CHMDS Community Health Minimum Dataset

CHP Community Health Program

DHHS Department of Health and Human Services

DPAC Divisional Performance Assurance Compliance

FOPMF Funded organisation performance monitoring framework

INI Initial needs identification

PEF Performance escalation framework

PHW Plan Victorian public health and wellbeing plan 2015–19

VAGO Victorian Auditor‐General’s Office

VHES Victorian Healthcare Experience Survey


Audit overview

Primary care is an integral part of Victoria’s health system—it includes services

such as general practice, pharmaceutical services, allied health, and community

nursing. In Victoria, the state and Commonwealth governments both fund the

provision of primary care.

Community health services are essential to Victoria’s primary care network.

They deliver a range of state‐ and Commonwealth‐funded programs, including

the state‐funded Community Health Program (CHP). There are 85 community

health services located in rural, regional and metropolitan Victoria. These

operate under two distinct legal and governance arrangements:

Fifty‐five community health services operate as part of regional or

metropolitan Victorian public health services. These ‘integrated’ community

health services are subject to the accountability frameworks of the broader

health service.

Thirty registered community health services operate as companies limited

by guarantee. To receive state government funding, they must register as a

community health service under the Health Services Act 1988.

The CHP aims to provide effective healthcare services and support to Victoria’s

priority populations. These populations receive priority access to services

because they are socially or economically disadvantaged, experience poorer

health outcomes, and have complex care needs or limited access to appropriate

healthcare services.

The Department of Health and Human Services (DHHS) administers the CHP

through funding paid to community health services. DHHS’s central office and

divisions—North, South, East and West—are responsible for delivering the CHP.

Each division operates several regional offices that are located across the state.

This audit examined whether the CHP effectively contributes to good healthcare

outcomes for Victoria’s priority populations. We analysed DHHS’s management

of the CHP, focusing on their strategic direction, access and demand

management, and performance monitoring.


The CHP is a valuable tool for DHHS to keep Victoria’s priority populations well,

out of hospital, and productive in society. However, maximising these benefits

requires DHHS to analyse demand and unmet need, and evaluate program

outcomes.

DHHS does not regularly monitor whether the CHP’s limited service hours are

being provided primarily to Victoria’s priority populations or what outcomes

these services are delivering. Nor does it know where there is demand for the

CHP or the extent of this demand across Victoria.

DHHS’s funding model and distribution methods are based on historical data

as opposed to analysis of changed population demographics. This may affect

community health services’ ability to deliver timely, effective and appropriate

care to Victoria’s priority populations. The community health services we

audited do not necessarily promote their services due to lack of capacity.

DHHS’s limited insights mean it is missing an important opportunity to take a

more strategic approach when funding community health services, informed

by a broad understanding of health service needs and utilisation across the

spectrum of care services.

Recognising this, DHHS is currently progressing a number of projects to

improve the CHP. These include considering a new funding model and making

improvements to the Community Health Minimum Dataset (CHMDS) and use

of its data. It will be necessary for DHHS to carefully monitor the results of this

work and use that information to refine the program. Though the CHP’s budget

is very small in comparison to that for acute care services, there is a clear

opportunity for DHHS to realise a significant return on its investment through

effective preventative and primary health care services for the most

disadvantaged Victorians.

Strategic management

Long‐term health strategies

DHHS has two long‐term strategies relevant to the CHP—Health 2040:

Advancing health, access and care (Health 2040) and the Victorian public health

and wellbeing plan 2015–19 (PHW Plan). DHHS has also released the Statewide

design, service and infrastructure plan for Victoria’s health system 2017–2037 to

operationalise Health 2040.

The CHP’s objective to provide effective healthcare services to Victoria’s priority

populations aligns with DHHS’s long‐term health strategies for better health,

access and care. However, DHHS’s ability to measure the CHP’s effectiveness or

contribution to DHHS’s strategic directions is limited because DHHS does not

have outcome measures or relevant data.

Conclusion

Findings


Evidence base for the CHP

DHHS’s Community health integrated program guidelines have strong

theoretical underpinnings and emphasise person‐centred care. While DHHS has

a range of demographic information, it does not incorporate on‐the‐ground

information, such as indices of disadvantage or demographic data, into the

CHP’s evidence base. This limits DHHS’s ability to translate theory into practice

and deliver effective healthcare services to the right people in the right place at

the right time.

DHHS should strengthen its evidence base by using population health data

and information from the CHMDS. DHHS demonstrated this approach when

identifying sites for the expansion of its Healthy Mothers, Healthy Babies

Program.

Funding for the CHP

DHHS implemented a new funding model in 2007. Since then, DHHS has not

reviewed the CHP’s funding. As a result, DHHS cannot assure itself that its

funding model supports the achievement of the CHP’s objectives. DHHS has

not reviewed:

the unit price, to ensure that it reflects the true cost of providing one hour

of service delivery

the total amount of funding for the CHP

the distribution of the CHP’s funding across community health services.

DHHS’s executive board has approved a proposal to undertake further research,

analysis and sector engagement to inform any future funding reform options.

Access and demand

Timely access to the CHP is important—it ensures that disadvantaged people

who cannot afford privately funded primary care receive the treatment that

they need. Timely treatment means individuals can have better health, avoid

hospital admissions and participate in society.

While DHHS can monitor who accesses the CHP, it does not do this regularly.

Therefore, DHHS has limited oversight of whether services are provided to

priority populations. DHHS’s analysis of current or unmet demand for the CHP

is limited and it does not know whether the CHP provides priority populations

with effective, timely and sufficient care.

DHHS’s key guidance document for managing access to the CHP is Towards a

demand management framework for community health services. DHHS has not

reviewed this guidance since its publication in 2008.

All the community health services we audited managed client intake in

accordance with DHHS’s guidance. Community health services commented

that they update the tools used to prioritise clients to reflect current research.

Community health services do this work in isolation from each other,

duplicating effort, and do not receive specific funding for this.


DHHS is currently evaluating future health demand in the northern growth

corridor by examining health risk factors, such as smoking and education levels.

It has also commenced a project to examine demand in community health

services by using past data and future population estimates.

Performance and quality

DHHS’s performance management system

While DHHS has some tools to monitor quality, the CHP’s current measuring,

monitoring and reporting system focuses on outputs and lacks performance

measures that assess whether care was timely and effective. As a result,

DHHS cannot provide assurance through its current performance management

system that the CHP delivers good healthcare outcomes for Victoria’s priority

populations. DHHS’s sole performance measure—the number of service hours

delivered—provides little insight into the efficiency, effectiveness or equity of

care.

In 2014–15, DHHS piloted a set of process‐based indicators to evaluate the

client’s administrative journey from admission to discharge. DHHS stopped

collecting this data in 2016–17, following feedback from the sector that

the data collection method imposed significant administrative burden on

community health services. DHHS is addressing some of its data issues through

a wide‐reaching improvement project and, after consulting with the sector, has

begun to embed some of the process‐based indicators into the CHMDS.

DHHS’s management of community health services

DHHS uses a standardised performance monitoring framework to govern

registered community health services. However, DHHS’s divisions apply certain

elements of the framework inconsistently, which leads to variances in

performance management across agencies.

Adding further variation to performance management in the sector, DHHS lacks

a specific performance monitoring framework for integrated community health

services. This limits DHHS’s oversight of integrated community health services,

which may, in turn, limit its ability to identify and address performance issues in

a timely and effective manner.

Program quality

As the CHP’s performance measures focus solely on quantity, DHHS has

limited oversight of the program’s effectiveness and impact beyond community

health services’ accreditation cycles. DHHS is currently extending its knowledge

of the CHP’s quality through the collection of process‐based indicators and

the Victorian Healthcare Experience Survey (VHES), which assesses client

satisfaction. While both tools provide insight regarding the provision of care and

represent a step in the right direction, DHHS must ensure that the results of the

survey are shared and used in a productive manner to yield value for the sector.

Process‐based indicators evaluate the implementation of care as opposed to its outcomes.


We recommend that the Department of Health and Human Services:

1. link its key strategic documents—such as Health 2040: Advancing health,

access and care and the Victorian public health and wellbeing plan

2015−19—to the Community Health Program (see Section 2.2)

2. ensure it collects purposeful data to monitor that CHP funded services are

provided to the identified priority populations (see Section 3.4)

3. review its CHP unit pricing to ensure that it meets the cost of providing

services to Victoria’s priority populations (see Section 2.4)

4. develop a more sophisticated funding model by identifying and

understanding the different service needs, demand and priorities for

community health service locations across Victoria, to inform the quantum

and distribution of funding (see Section 2.4)

5. in conjunction with community health services, regularly review and revise

the demand management framework and clinical priority tools to ensure

that they reflect optimal practice (see Section 3.3)

6. have internal and publicly available quality performance measures that

assess program equity and client satisfaction, while working towards

outcome measures for the Community Health Program (see Section 4.3)

7. provide divisional offices with guidance that standardises their monitoring

of community health services (see Section 4.5).

We have consulted with DHHS, Bendigo Health, East Wimmera Health Service,

Monash Health, Peninsula Health, Bendigo Community Health Service, cohealth,

Gippsland Lakes Community Health, Latrobe Community Health Service, North

Richmond Community Health and Orbost Regional Health. We considered their

views when reaching our audit conclusions. As required by section 16(3) of the

Audit Act 1994, we gave a draft copy of this report to those agencies and asked

for their submissions or comments. We also provided a copy of the report to the

Department of Premier and Cabinet.

The following is a summary of those responses. The full responses are included

in Appendix A.

DHHS acknowledged that the audit provides an opportunity to build on existing

initiatives supporting community health services, especially for disadvantaged

Victorians. DHHS accepted all our recommendations and provided an action

plan detailing how these recommendations will be implemented, including its

intention to form a Community Health Taskforce to consult with the sector and

assist DHHS to implement the recommendations.

cohealth responded and was supportive of our recommendations, noting that

their implementation will require resourcing for both DHHS and the community

health sector.

Recommendations

Responses to recommendations


Audit context

Primary care is a fundamental pillar of Victoria’s health system—it includes

services such as general practice, pharmaceutical services, allied health and

community nursing. Well‐coordinated primary care should improve the health

and wellbeing of Victorian communities, enable the effective treatment of

people with chronic diseases, and enhance outcomes for disadvantaged

Victorians.

Generally, primary care is a person’s first point of contact with the broader

health system and it becomes the central point for ongoing, coordinated

treatment. Acute care, in contrast, involves specialised, short‐term intervention

to address severe illness or injury. Acute care generally occurs in a hospital

setting and includes admitted and non‐admitted services. A good primary care

system should alleviate pressure on the acute sector through the prevention

and effective management of chronic diseases, reducing the number of

avoidable hospital admissions per year.

In Victoria, the state and Commonwealth governments fund the provision of

primary care. The Commonwealth Government provides the majority of funding

through entitlement programs such as the Medicare Benefits Schedule and the

Pharmaceutical Benefits Scheme. Private allied health practitioners also operate

across Victoria and provide an additional option for people seeking healthcare.

Community health services are an integral part of Victoria’s primary care

network. They aim to reduce social inequity through effective consumer

engagement and have strong connections to their local areas.

Community health services occupy a unique role in the Victorian landscape as

a state‐funded provider of primary care services. They work alongside other

Commonwealth and privately‐funded programs to deliver a diverse range of

clinical and non‐medical services. They prioritise access for people who

generally have the poorest healthcare outcomes and are the most

disadvantaged.

Community health services, however, are not the sole provider of primary care

to disadvantaged people. These groups also access other service types, such as

bulk‐billing general practitioners.

1.1 Community health services


Importantly, community health services are ‘platform providers’ of both health

and social services—they can deliver up to 30 different programs through

60 different funding streams. Community health services thus facilitate a broad

range of both state and Commonwealth initiatives that holistically address their

clients’ needs.

There are currently 85 community health services across Victoria—see

Figures 1A and 1B. These differ in size and the range of programs they offer.

Most of the state’s community health services formed in the 1970s to deliver

the social model of health. The social model of health recognises that

Victorians have unequal access to education, healthcare, cultural activities and

employment. It aims to enhance outcomes for disadvantaged Victorians by

providing equitable and affordable healthcare. Fundamentally, the social model

acknowledges that a person’s environment influences his or her health in

addition to disease and injury.

Figure 1A Community health services across Victoria

Note: LGAs = local government areas.

Source: DHHS.


Figure 1B Community health services across metropolitan Melbourne

Note: LGAs = local government areas.

Source: DHHS.

There is great diversity across the community health sector, not just in the

services they provide, but also in their operating models and their strategic

priorities. While some organisations are small local services, primarily focused

on the delivery of health services to disadvantaged groups within their local

areas, others have grown or amalgamated to be very large organisations and

operate from multiple ‘satellite sites’ across Victoria.

In Victoria, community health services operate under two distinct legal and

governance arrangements and have different accountability mechanisms under

legislation:

Fifty‐five community health services are part of rural or metropolitan public

health services. They are subject to the regulatory provisions set out in

Division 9B of the Health Services Act 1988.

Thirty registered community health services are companies limited by

guarantee. Registered community health services are subject to the

regulatory provisions set out in Division 6 of the Health Services Act 1988.


The CHP aims to deliver effective primary care services to Victoria’s priority

populations. According to the CHP’s guidelines, ‘priority populations’ refers to

people who are socially or economically disadvantaged, experience poorer

overall health outcomes, and have complex care needs or limited access to

appropriate healthcare. These priority populations include:

Aboriginal and Torres Strait Islander people

people with an intellectual disability

children in out‐of‐home care

people with a mental illness

refugees and asylum seekers

people experiencing or at risk of homelessness.

DHHS administers the CHP through a flexible funding source paid to community

health services. Community health services deliver the CHP in addition to a

broader suite of state‐ and Commonwealth‐funded initiatives.

Figure 1C shows the range of state‐funded primary and community health

programs that community health services can deliver.

DHHS funds some community health services to deliver particular programs.

For example, the Healthy Mothers, Healthy Babies Program—a specialised

initiative—targets vulnerable, at‐risk pregnant women and is only available in

20 local government areas. In contrast, the CHP is universal to all community

health services.

Figure 1C State‐funded primary and community health programs

Note: MDC=multidisciplinary centre.

Source: VAGO based on DHHS documentation.

Community Health

‘Platform’

CHP

Women’s Health

Family Planning

Innovative Health

Services for Homeless Youth

Family and Reproductive

Rights Education Program

Integrated Chronic Disease

Management

Refugee and Asylum Seeker Health

Healthy Mothers, Healthy Babies Program

MDC Communtiy Health Nurse

Community Asthma Program

1.2 The Community Health Program


As shown in Figure 1D, the CHP funds community health services to deliver

a range of activities, such as general counselling, allied health and nursing

services. Community health services—in conjunction with DHHS—determine

the mix of activities that they deliver. This flexible funding source enables

community health services to customise the CHP to meet the needs of their

local communities.

Figure 1D Activities funded by the CHP


Client profile

In 2016–17, the CHP provided 705 318 hours of allied health, generalist

counselling and nursing services to 181 977 individual registered clients.

Of these:

57.7 per cent were female

1.9 per cent identified as either Aboriginal or Torres Strait Islander

2.9 per cent identified as a refugee

17.6 per cent had a chronic and complex condition

46 per cent had a concession card.

CHP

Audiology

Dietetics

Occupational therapy

Physio‐therapy

PodiatrySpeech

pathology and therapy

Nursing

Counselling and

casework

Initial needs identification


DHHS’s central office has statewide responsibility for managing the CHP. This

includes collecting and monitoring performance information, leading service

improvement initiatives, and developing and implementing key policy and

strategic directions.

DHHS’s regional offices monitor the CHP’s delivery by community health

services and escalate performance issues to the central office when required.

The central office provides key support through the provision of data and

performance reports.

The Health Services Act 1988 establishes Victoria’s public health services, public

hospitals and multipurpose services as independent legal entities. Integrated

community health services are part of rural or metropolitan health services.

They are covered by the regulatory provisions set out in Division 9B of the

Health Services Act 1988. A key accountability mechanism is the Statement

of Priorities which is negotiated annually by DHHS with each Victorian public

health service and public hospital.

Registered community health services are governed by the regulatory provisions

set out in Division 6 of the Health Services Act 1988. A key accountability

mechanism is the service agreement established between DHHS and the funded

agency.

Overall the legislative and accountability frameworks provide both integrated

and registered community health services with the flexibility to make decisions

about services they deliver with state government funding, based on local

needs.

Both types of community health services are subject to established

performance monitoring processes, and DHHS may intervene if there are

concerns about the delivery of funded programs and services.

DHHS funds community health services to deliver a defined number of hours of

primary care. While community health services must deliver care within these

thresholds, they have the flexibility to develop innovative approaches that

reflect the needs of their local areas.

The CHP promotes a person‐centred approach that assists clients to manage

their own care, improve their understanding of the health system, and make

informed decisions. It encourages community health services to undertake a

team‐based approach and deliver evidence‐based services that ‘wrap around’

the individual—that is, multiple practitioners should collaborate to create a

care plan that addresses the client’s needs. The CHP also promotes early

intervention, as this reduces the risk of further deterioration and produces

better outcomes for clients.

1.3 Department of Health and

Human Services

1.4 Service delivery


In 2017–18, the 85 community health services will receive approximately

$105 million in funding to deliver allied health and nursing services under the

CHP. This equates to around one million hours of service delivery. When

compared to the overall Victorian health budget, the CHP makes up less than

1 per cent of Victoria’s expenditure.

The CHP’s funding is based on units and measured in service hours. In 2017–18,

community health services will receive $104.93 for each hour of allied health

practice and $93.62 for each hour of nursing that they deliver. This unit price

must cover the community health services’ travel expenses, general operating

costs, rent, access coordination and the maintenance of facilities.

DHHS funds the CHP to provide effective healthcare and support to Victoria’s

priority populations. Community health services have the flexibility to

develop innovative approaches to service delivery, such as the formation

of multidisciplinary teams to support clients through a ‘wrap around’ model

of care.

This audit is important because it is the first audit we have done of the CHP. It

is also important because the CHP provides healthcare to priority populations

that otherwise may not be able to afford these types of services. Along with

other important primary care services—such as general practice—these forms

of care can improve clients’ health and wellbeing outcomes and reduce

avoidable hospital admissions.

This audit examined whether the CHP effectively contributes to good healthcare

outcomes for Victoria’s priority populations. We analysed DHHS’s management

of the CHP, with a particular focus on its strategic direction, access and demand

management, and performance monitoring.

As a follow‐the‐dollar audit, we also included 10 community health services:

four integrated health services—Bendigo Health, East Wimmera Health

Service, Monash Health and Peninsula Health

five registered community health services—Bendigo Community Health

Service, cohealth, Gippsland Lakes Community Health, Latrobe Community

Health Service and North Richmond Community Health

one multipurpose health service—Orbost Regional Health.

We focused on how community health services manage demand and how they

implement DHHS’s guidelines.

The audit methods included:

interviews with DHHS and community health service staff

reviews of strategies, program delivery documents, policies, procedures and

waiting lists

site visits to all 10 community health services

analysis of the CHMDS.

1.5 Program funding

1.6 Why this audit is important

1.7 What this audit examined

and how


We conducted our audit in accordance with section 15 of the Audit Act 1994

and ASAE 3500 Performance Engagements. We complied with the

independence and other relevant ethical requirements related to assurance

engagements. The cost of this audit was $440 000.

The remainder of this report is structured as follows:

Part 2 examines the strategic management of the CHP

Part 3 examines access and demand management for the CHP

Part 4 examines the use of outcomes measures for the CHP.

1.8 Report structure


Strategic management

DHHS’s strategic management of the CHP is important to ensure the program

has the resources required to meet its overarching objective. It is also important

that DHHS can measure the contribution the CHP makes to long‐term health

strategies.

In this part of the report, we evaluate whether the CHP supports DHHS’s

strategic direction and fulfils its overarching objective of delivering effective

healthcare to Victoria’s priority populations. We also assessed the CHP’s

evidence base and examined whether its funding model is sound, regularly

reviewed and strategically aligned.

DHHS’s strategic management of the CHP partly supports the achievement

of the program’s objectives. A strong evidence base supports the CHP’s model

of care, but DHHS could strengthen this by using population health data and

information from the CHMDS to better target effort. While the CHP aligns with

DHHS’s long‐term health strategies, DHHS is unable to measure the contribution

that the CHP makes to those strategies.

While the current funding model supports some flexibility in the delivery

of services, the CHP’s funding model does not support DHHS to achieve the

program’s objectives. DHHS does not know whether the unit price, funding for

the CHP and the allocation of funding provide effective healthcare to Victoria’s

priority populations. Further work is required to develop a funding model that

aligns with the purpose of the CHP.

2.1 Conclusion


Health 2040: Advancing health, access and care

The Victorian Government released Health 2040 in December 2016 after

consultation with the public and the sector. By 2040, it aims for all Victorians to

experience:

better health—building skills and delivering support to be healthy and well

better access—fair, timely and easier access to care

better care—world‐class healthcare every time.

Statewide design, service and infrastructure plan for Victoria’s health system 2017–2037

The Victorian Government released the Statewide design, service and

infrastructure plan for Victoria’s health system 2017–2037 in December 2017 to

support the delivery of Health 2040’s vision. It provides a blueprint for health

service and infrastructure investment for the next 20 years.

The plan includes five priority areas that will deliver Health 2040’s three

objectives. The five priority areas are:

Priority area 1: Building a proactive system that promotes health and

anticipates demand

Priority area 2: Creating a safety and quality‐led system

Priority area 3: Integrating care across the health and social service system

Priority area 4: Strengthening regional and rural health services

Priority area 5: Investing in the future—the next generation of healthcare.

Each priority area specifies a number of focuses and actions to implement the

plan’s five‐year goals and 20‐year outcomes. Priority areas 1 and 3 relate

directly to community health. The relevant actions include:

integrating prevention and early intervention

expanding primary care service options

establishing health and wellbeing hubs.

The plan states that community health is a central part of Victoria’s healthcare

system. It commits to consolidating the sector’s role by including community

health in provider alliances, and health and wellbeing hubs. Importantly, it

acknowledges that DHHS’s current funding and organisational arrangements

limit the capacity of such services to maximise integration. This may affect the

delivery of services to people with chronic and complex needs.

Overall, Health 2040’s vision for better health, access and care clearly aligns

with the CHP’s objectives to provide timely, affordable and effective healthcare

to Victoria’s priority populations.

As DHHS launched the plan in December 2017, it is too early to see progress.

However, DHHS has formed an internal steering committee to oversee action

and has committed to report on progress against the plan every two years.

2.2 Long‐term health strategies


Victorian public health and wellbeing plan 2015–19

The Public Health and Wellbeing Act 2008 mandates that Victoria must have a

public health and wellbeing plan that identifies the state’s needs, examines

data and establishes key objectives. The current PHW Plan acknowledges the

correlation between poor health and other social inequalities, such as limited

access to housing, education, employment and public transport. It aims to

reduce the avoidable burden of disease and injury so that all Victorians can

experience the highest attainable standards of health, wellbeing and social

participation. In October 2016, DHHS released an associated document—the

Victorian public health and wellbeing outcomes framework (outcomes

framework). This outlines DHHS’s vision for a disease‐free Victoria by

progressively improving people’s health.

The outcomes framework contains indicators, targets and measures for each

of DHHS’s strategic domains. These enable DHHS to track changes in Victorians’

health and wellbeing levels over time at a population level. Two population level

targets explicitly relate to the mitigation of chronic disease, including:

25 per cent decrease in premature deaths due to chronic disease by 2025

from 2010 baseline

halting the rise in diabetes prevalence by 2025.

The objective of the CHP aligns with the PHW Plan’s overall vision for a healthier

Victoria. The CHP helps disadvantaged people—who statistically are shown to

experience poorer health outcomes—deal with issues such as chronic disease

and receive support to adopt preventative health behaviours. In line with the

PHW Plan, the CHP provides a place‐based approach to healthcare.

The work done by community health services directly supports the measures

in the outcomes framework, and the CHP prioritises services for people with

chronic diseases. However, DHHS does not collect data that enables it to

measure the CHP’s contribution to the PHW Plan’s vision.

The outcomes framework notes that rigorous evaluation of programs and

continuous efforts to understand what works in different contexts should

complement its reporting cycle. DHHS has not undertaken any reviews or

assessments of the CHP to understand its effectiveness or impact.

An effective evidence base for the CHP should:

have sound theoretical underpinnings through the use of current, reliable

and relevant research

analyse demographics and indices of disadvantage at the local level to

ensure that services and funding are appropriately targeted and address

demand

rigorously evaluate the program’s impact on Victoria’s priority populations.

Place‐based approaches to healthcare aim to provide Victorians with access to locally available and integrated services.

2.3 Evidence base for the CHP


Theoretical underpinnings

DHHS published the Community health integrated program guidelines in

March 2015. These are a key component of the CHP’s underlying evidence base.

According to the guidelines’ principles, care must:

be person centred, culturally responsive, goal directed and evidence based

take a team approach that supports the client’s health literacy levels

encourage early intervention

engage with health promotion.

The philosophy of person‐centred care is fundamental to the CHP.

Person‐centred care supports clients to participate in decision‐making while

respecting their preferences, diversity and background. DHHS established the

CHP’s underlying principles following a comprehensive literature review in

September 2012. This research component of the CHP’s evidence base complies

with optimal practice.

DHHS’s use of information

While DHHS has a range of demographic information, it does not incorporate

this, indices of disadvantage or analysis of local demand issues into the CHP’s

evidence base. This information would strengthen the CHP, and enable DHHS

to appropriately target its services and ensure that priority populations

receive effective, timely and appropriate care. DHHS has begun to incorporate

demographic and local demand information for other state‐funded community

health initiatives. For example, when identifying sites for the expansion of its

Healthy Mothers, Healthy Babies Program, DHHS assessed various indicators of

disadvantage, such as the concentration of child protection reports across the

state. DHHS should apply the same methodological rigour to the CHP to ensure

that it delivers services based on robust and practical evidence.

The CHP’s impact on priority populations

Likewise, DHHS has limited oversight of the CHP’s effectiveness. As discussed

in Part 4 of this report, DHHS’s key performance measure for the CHP focuses

solely on the quantity of service hours delivered. This impairs DHHS’s ability to

improve and innovate the CHP’s service delivery model, as it lacks information

regarding the quality, appropriateness and timeliness of care.

Overall, DHHS’s evidence base for the CHP is lacking—it does not adequately

reflect Victoria’s needs and priorities, and provides limited insight into the

impact of the program.

Community health services’ contribution to the evidence base

The audited community health services advised us that they maintain their own

evidence base. These reflect the needs of their local areas and align with their

broader strategic directions. DHHS should leverage the skills and knowledge of

the sector when planning service delivery.

Health literacy is a person’s ability to understand health‐related information and use this information to inform his or her decisions and actions. Good health literacy is important, as it influences a person’s health and experience of the healthcare system.


For example, Bendigo Community Health Service funds a Strategy, Planning and

Analysis team to evaluate current research and produce guidance. This ensures

that its services align with optimal practice. In July 2017, the team published an

internal guide Scoping of Service Delivery Models for Generalist Counselling,

which outlines the benefits, risks and challenges of various approaches to care,

such as telephone psychotherapy and online counselling. Guidance like this

enables Bendigo Community Health Service’s clinicians to offer innovative

services and make informed treatment decisions while maximising their

client-facing time. DHHS does not specifically fund research teams at

community health services, however, Bendigo Community Health Service has

found that the advantages outweigh the cost. DHHS could better leverage such

work across the CHP.

DHHS funds community health services to deliver the CHP to Victoria’s priority

populations. To do this effectively, DHHS should:

ensure that the CHP’s unit prices for one hour of nursing and one hour of

allied health care accurately reflect the current costs of service delivery

ensure the amount of funding allocated to the CHP meets the needs of the

Victorian population

ensure that the CHP’s funding is distributed according to need.

The evolution of the CHP’s funding model

DHHS’s unit pricing for service delivery aims to fund an hour of care, as well as

the community health services’ associated costs.

DHHS adopted its previous model, the Primary Health Funding Approach, in

July 2002. It included three major components:

a unit price for service delivery

block funding for health promotion activities (no longer part of the CHP

funding model)

a resourcing component to support any associated infrastructure costs.

DHHS commissioned a review of the Primary Health Funding Approach in 2004,

which evaluated different aspects of the model. This included a survey of

community health services’ expenditure, visits to 20 community health services

and document analysis. The consultant’s report recommended that DHHS

collect further evidence to inform the unit price.

DHHS’s ‘Frequently Asked Questions’ fact sheet, dated October 2008,

introduces its new funding model. The fact sheet states that DHHS undertook

further work following the consultant’s report before deciding on a model.

2.4 Funding for the CHP

Governments may fund programs through ‘block funding.’ This means that the money comes with general spending instructions. Activity‐based funding, on the other hand, has stricter provisions.


DHHS formed a steering committee to oversee the implementation of the

funding model. Meeting notes from the steering committee note that the

unit price for the CHP is the same as that of the Home and Community Care

Program, for people aged over 65, which has transferred to the Commonwealth,

and the continuing Home and Community Care Program for Younger People

funded by the Victorian Government. However, DHHS has not been able to

provide us with the evidence of further work undertaken to inform the

development of the Primary Health Funding Approach for the CHP.

DHHS’s current funding model

Unit costing

DHHS annually updates its funding requirements through the Policy and funding

guidelines. This document specifies the current unit price for service delivery.

DHHS advised that the CHP’s unit prices rise in line with DHHS’s internal

indexation, approved by the Victorian Government. The level of indexation has

been between 1.5 per cent and 2.5 per cent each year for the past five years.

However, DHHS has not reviewed the unit cost for the CHP since 2007—so it

does not know whether the unit price accurately reflects the current cost of

care in community health services.

Funding amount for the CHP

The CHP currently receives approximately $105 million in funding for the

delivery of nursing and allied health services. The program received additional

recurrent funding of about $1 million from 2013–14. However, DHHS has

not undertaken a significant review of the CHP’s total funding allocation to

determine whether it addresses the needs of Victoria’s priority populations.

Funding distribution

DHHS describes its current CHP funding distribution model as population based.

However, DHHS lacks documentation to show how it developed the model or

what calculations it uses to allocate funding to community health services.

In a December 2013 memorandum to the Minister for Health regarding

additional recurrent funding, DHHS noted that it allocated the funding according

to population growth, social disadvantage, the catchment population of children

and the percentage of developmentally vulnerable children. This appears to be a

sound approach, however, DHHS cannot produce any evidence to demonstrate

its application.

DHHS has not reviewed community health services’ funding allocations since

2007. Community health services located in growth corridors have not received

an increase in funding proportionate to the increase in their area’s population.

In addition, DHHS’s funding allocation does not recognise demographic changes,

such as increases in disadvantage.

Therefore, the funding model may compromise the CHP’s ability to provide

effective healthcare to Victoria’s priority populations.


Proposed new funding model

DHHS is currently considering the development of new funding models for the

spectrum of healthcare that Victoria funds and manages, including the CHP.

DHHS has undertaken preliminary work, including commissioning research and

a literature review. This includes consideration of a new funding model based on

packaged funding for specific cohorts whereby community health services are

funded for the number of enrolled clients at their service.

Clients with greater complexity and those from the CHP’s priority populations

would attract higher payments. DHHS’s executive board has approved further

research, analysis and engagement with the sector before it implements any

reform options.

This proposed funding model is more closely aligned to the objectives of the

CHP than DHHS’s current funding model.


Access and demand

Timely access to primary care services—such as the CHP—is important for

Victoria’s priority populations, as early intervention may prevent people’s

conditions from worsening. This can also reduce pressure on the health services

providing acute care.

DHHS provides community health services with set CHP funding on an annual

basis. With limited resources available, it is important for community health

services to manage access and demand at the local level. Similarly, DHHS must

monitor the state’s access and demand issues to effectively oversee the CHP.

In this part of the report, we examine DHHS’s guidance regarding the

management of access and demand, and its implementation at community

health services. We also assess the demand management analysis undertaken

by DHHS and community health services to ensure that it supports the provision

of timely and effective care.

Timely access to the CHP is important to prevent individuals being admitted

to hospital and to support their health and wellbeing. At a local level, the

community health services we audited had effective strategies in place to

manage their known demand. However, as a whole, DHHS cannot demonstrate

that the CHP is providing timely and equitable access across the state and

meeting the demand and needs of its priority populations.

Community health services require guidance on access and demand procedures

to deliver the CHP effectively. DHHS’s guidance should ensure that community

health services prioritise access for clients who are most in need.

DHHS’s framework for managing demand

DHHS’s framework for managing access to the CHP is outlined in its key

guidance document Towards a demand management framework for community

health services (demand management framework). The demand management

framework assists community health services to prioritise their clients and

address pressures at each stage of service delivery—inflow, flow through and

outflow.

3.1 Conclusion

3.2 Guidance for access and demand


Inflow

The demand management framework provides community health services with

a model for inflow—or intake of clients. The initial needs identification (INI) is

an important screening process that aims to identify a client’s presenting and

underlying needs. DHHS provides Service Coordination Tool Templates for INI,

which community health services use to seek information about clients’ living

arrangements, health behaviours and psychosocial status. In 2016–17, INI

accounted for almost 8.5 per cent of the total service hours delivered. This

demonstrates the importance of funding for this process.

To ensure community health services treat clients in the appropriate order,

INI enables practitioners to triage clients as priority 1, 2 or 3. Priority 1 clients

require urgent intervention, whereas priority 3 clients can safely wait for care.

There are, however, no clinically recommended treatment time frames for each

priority group.

To facilitate the triage process, DHHS provides community health services with

two sets of tools for prioritising clients:

a generic priority tool that identifies priority populations, those at risk of

imminent harm, and people with multiple complex needs

clinical priority tools for seven of the CHP’s allied health specialties.

Flow through

Flow through describes the client’s journey through the community health

service until they exit. The guidelines provide a number of processes to

effectively manage client flow through. These include:

waiting list management

appointment processes

particular models of service delivery, such as group‐based work or

goal‐based intervention.

The guidelines are not prescriptive and provide community health services with

the autonomy to implement and tailor processes to their individual practices.

Outflow

Outflow focuses on ensuring clients exit the community health service safely

and appropriately. The demand management framework states that community

health services should start planning a client’s exit from the service at the first

appointment. There are a number of reasons that people will exit care,

including:

only needing short‐term intervention

reaching their goals

needing to be referred to another service for different care.


Usefulness of the demand management framework

DHHS published the demand management framework in 2008. While it provides

guidance for community health services, it is now out of date. For example, it

refers to A Fairer Victoria—a social strategy launched in 2005.

The demand management framework contains suggestions for community

health services on how to undertake different processes, but since DHHS

produced this guidance, some community health services have implemented

different demand management processes—for example, for dealing with clients

cancelling or failing to attend appointments. Community health services we

audited commented that they were not aware of what demand management

techniques other services were using and were interested in having more

guidance on demand management techniques.

DHHS should review the demand management framework to determine

whether it is comprehensive, evidence based and in line with current processes.

Community health services are responsible for administering the demand

management framework. We discussed with community health services how

they implement the framework in their day‐to‐day work.

Inflow

Various sources—such as general practitioners, health services and other

community organisations—refer clients to the CHP. Individuals can also refer

themselves to community health services.

Service access

All the audited community health services have service access staff to manage

client intake. Typically, service access staff receive referrals from internal or

external practitioners, or calls directly from clients. Service access staff are

generally responsible for determining whether a client is appropriate for

the CHP, initially triaging the client and scheduling an appointment. If no

appointments are available, the client may be placed on a waiting list. This

process takes anywhere from 10 minutes to an hour and depends on the

client’s complexity.

Community health services have guidelines for service access staff that are

consistent with DHHS’s demand management framework. Coordinating service

access is an important process, as it ensures that clients receive the right care at

the right time and can access services efficiently and effectively. DHHS does not

specifically fund service access through the CHP, but incorporates it into the

hourly cost of care.

3.3 Administering the demand management framework


As discussed in Part 2, DHHS has not reviewed the CHP’s unit price and

consequently does not know if it adequately covers community health services’

cost of delivering services.

Priority tools

Service access staff first assess incoming clients against the generic priority tool.

If the client is from a priority group, they receive priority 1 status. If not, service

access staff use the clinical priority tools to determine whether an individual is a

priority 1, 2 or 3.

DHHS developed clinical priority tools in conjunction with community health

services and consumers in 2008. It formed working groups for funded allied

health specialities—nursing, counselling, dietetics, adult and paediatric

occupational therapy, physiotherapy, podiatry and speech pathology.

All the audited community health services commented that DHHS’s clinical

priority tools are general in scope. However, as shown in the case study in

Figure 3A, this gives community health services the flexibility to adapt them

to reflect local practice.

Figure 3A Case study: Bendigo Community Health Service’s podiatry service

Bendigo Community Health Service has a busy podiatry service. The podiatry team has created its own clinical priority tools to maintain consistency among practitioners. It uses the University of Texas (UT) Foot Wound Classification System to grade wounds according to their severity.

This system enables the health service’s podiatrists to objectively assess their clients’ needs. For example, using the health service’s clinical priority tool, a client with a category 3 wound according to UT’s system (a wound that penetrates the bone or joint and requires immediate medical attention) would be categorised as priority 1.

In addition, Bendigo Community Health Service collaborates with Bendigo Health’s integrated community health service to ensure that high‐risk clients receive clinically appropriate care in a safe environment. This partnership represents best practice, as it aims to ensure that clients receive the right care at the right time in the right place.

Source: VAGO based on Bendigo Community Health Service documentation.

As DHHS last updated its clinical priority tools in 2008, community health

services commented that they had to adjust DHHS’s clinical priority tools to

reflect current research.

In 2008, DHHS engaged consultants to evaluate initial use of the tools at eight

community health services. They evaluated the tools’ use by service access staff

and clinicians, and tested their effectiveness in further discussions with clients.


The consultants presented a report of their findings to DHHS in 2009. The report

raised specific issues with the clinical priority tools and made a number of

general recommendations, including that DHHS:

implement a mechanism for continual feedback on the clinical priority tools

so DHHS can understand how they are used in practice

review the relevant literature on clinical disciplines to ensure the clinical

priority tools reflect an evidence‐based approach.

DHHS advised that it would consider these recommendations in the context of

its resources and priorities. There is no evidence that DHHS has implemented

recommendations from this 2009 review.

DHHS’s clinical priority tools aim to provide consistency in the way community

health services prioritise CHP clients across Victoria. It is positive that

community health services have modified the tools to reflect their local

practice. However, community health services are doing this independently.

This means that all 85 community health services are spending time and

resources updating the tools, despite DHHS neither facilitating nor funding the

process. In addition to this duplication of effort, there is a risk that community

health services may have inconsistent guidelines which means some clients with

the same level of need may not receive the same level of access or timely

intervention.

DHHS should update the clinical priority tools to promote consistent practice

and reduce duplicated effort among community health services.

Flow through and outflow

The amount of time and resources required to treat individual clients influences

the community health service’s ability to treat new people. This impacts the

number of clients that flow through community health services. Almost all

community health services reported high demand for their allied health

specialties. To ensure that new clients flow through efficiently and effectively,

community health services have strategies that manage access. Strategies

include:

running group sessions for some services, such as speech therapy

regularly reviewing client care needs to identify the earliest possible exit

from the community health service.

Analysis of the CHMDS shows that 90 per cent of the CHP’s clients access

services for 10 sessions or fewer—see Figure 3B. While some clients may only

need short‐term intervention, this demonstrates that community health

services are implementing strategies to manage outflow and provide access to

more clients.


Figure 3B Clients accessing CHP treatment

Note: The data range 11–370 is an aggregated figure. Source: VAGO based on DHHS documentation.

DHHS’s oversight of access at community health services

DHHS receives quarterly data from community health services on the number

of service hours delivered in the CHP. Divisional offices use this data to assess

whether community health services meet their targets, however, DHHS has no

oversight of whether access is equitable. This is due to limitations in DHHS’s

performance measures and dataset, discussed in Part 4.

Measuring demand is important for the CHP—at a whole‐of‐state level, it allows

DHHS to determine whether the CHP receives adequate funding and is meeting

community needs.

DHHS’s past and current demand measurement processes

Managing demand for the CHP is complex. There is no evidence that DHHS has

undertaken any analysis of potential or hidden demand across Victoria.

However, DHHS has recently commenced a demand forecasting project.

0

10 000

20 000

30 000

40 000

50 000

60 000

70 000

1 2 3 4 5 6 7 8 9 10 11–370

Client revisits

Registeredindividual clients

3.4 Demand in community

health services


DHHS’s oversight of current demand pressures is further limited, because the

CHMDS contains incomplete and inaccurate data fields. For example, DHHS

requires community health services to collect the concession card status of CHP

clients, however, this field is blank or inadequately described in 44.5 per cent of

records. This compromises DHHS’s ability to understand whether community

health services adequately manage demand to ensure that priority populations

receive preferential and timely access to care. DHHS is undertaking a data

streamlining project which it believes will support improved data collection

practices by agencies. DHHS also does not collect waiting list data, which further

limits its oversight of the state’s demand pressures.

As discussed in Part 4, DHHS’s key performance measure for the CHP focuses

solely on the number of service hours delivered. Without further information,

DHHS is unable to determine whether the CHP adequately services its priority

populations with sufficient care, in the right place and within a reasonable time.

Action taken to improve DHHS’s demand measurement processes into the future

DHHS has begun to evaluate demand in key catchment areas to address the

gaps in its knowledge. For example, in August 2017, it produced a draft version

of the Design, service and infrastructure plan for the Northern Growth Corridor.

The report provides a high‐level framework for planning in the northern growth

corridor, which has experienced rapid population growth in recent years. The

document profiles the catchment’s diversity, service use, level of socioeconomic

disadvantage, access to education, and prevalence of health risk factors, such

as smoking rates. It aims to strengthen the northern growth corridor’s existing

healthcare network and enhance the flexible use of services to lessen disparities

for disadvantaged Victorians. DHHS intends for future modelling to explore the

rate of people moving into the area as well as projected use of services.

In addition, DHHS’s System Intelligence and Analytics Branch has recently

produced a project specification to understand how current and past

investments in community health services have influenced activity patterns.

It intends to use past activity data—2008–09 to 2016–17—and population

estimates to gain insight into future activities and demand, and increase

DHHS’s knowledge of its clients. The document outlines a detailed

methodology, identifies various risks, and assumes that no changes will be made

to the CHP’s funding formula. The project specification demonstrates DHHS’s

commitment to improving its oversight of demand pressures in community

health services and is a step in the right direction.


Community health services’ demand measurement processes

DHHS’s demand management framework states that community health services

should keep waiting lists to effectively manage their clients. The audited

community health services all keep waiting lists and use these to monitor

access. If possible, community health services avoid placing clients on waiting

lists, as long delays can discourage and frustrate both parties. Waiting lists cause

an administrative burden, as staff must generate acknowledgement letters,

regularly maintain the waiting list, and conduct follow‐up calls and status

updates. Community health services have various strategies for managing

demand, including:

involving practitioners and clinicians in more detailed screening to ensure

that clients are appropriately triaged, as this influences waiting times and

the provision of effective care

undertaking group therapy where clinically appropriate, for example,

speech pathology for children aged five and under

expediting access to speech pathology services for children about to start

school.

DHHS acknowledges that funding for the CHP is capped, which has

consequences for community health services’ ability to manage their demand

pressures. DHHS also acknowledges the significance of robust service planning

and funding model development to support community health services to

improve access for priority populations.

These funding constraints have consequences for community health services’

ability to manage their demand pressures. For example, five community health

services that we spoke to advised that they are unable to advertise their

services or proactively seek clients, as they cannot provide care to all eligible

people within the community.

Gippsland Lakes Community Health noted that in rural areas, people are

under‐serviced and need is often only noticed when people travel to other

areas to access service. Therefore, people in rural areas need services placed

in locations where there is demand to improve access.

In addition, workforce retention rates also affect community health services’

ability to meet demand. Sometimes, allied health professionals are difficult to

recruit. Rural and remote community health services are affected by this more

severely, as they are commonly the sole providers of allied health services in

their communities. Such allied health positions may remain vacant for extended

periods, which affects the community health service’s ability to care for its local

population.


For example, Orbost Regional Health has difficulty attracting allied health

specialists—particularly physiotherapists—to its region, as it is in an isolated

rural location. It often relies on graduate physiotherapists to fulfil its needs,

however, most work for the community health service for only 12–18 months

before leaving. When Orbost Regional Health is without a physiotherapist, it

refers its clients to neighbouring services, such as Gippsland Lakes Community

Health. The health service advised that this impacts access for its clients, as the

region lacks regular public transport services.

To address this issue, Orbost Regional Health collaborates with different

community health services across the region to share allied health specialists

when they are in limited supply. For example, after the health service was

unable to recruit a physiotherapist, it arranged for one from Bairnsdale to visit

on a weekly basis so that its clients could continue to receive timely care.

Sometimes, rural community health services—such as Orbost Regional Health

—will fill service gaps with locums, however, this is an expensive option and is

considered a last resort.


Performance and quality

Performance monitoring and reporting promotes transparency, good

governance and effective management. It delineates the roles and

responsibilities of agencies and is government’s key accountability mechanism.

Monitoring and reporting cycles require fair, relevant and consistent measures

to effectively scrutinise performance.

DHHS collects data from various sources—such as feedback from staff and

clients, clinical activity and local intelligence—to paint a picture of day‐to‐day

performance at community health services.

In this part of the report, we examined whether DHHS’s performance

management system allows it to:

demonstrate achievement of the CHP’s objectives

hold community health services accountable for their performance

test and evaluate evidence‐based strategies for broader policy‐making

within the sector

improve the CHP and its service delivery model.

DHHS’s performance management framework is unable to assess whether the

CHP meets its objective of delivering effective healthcare services and support

to Victoria’s priority populations. DHHS lacks insight regarding the timeliness,

equity, appropriateness or impact of care because its public and internal

reporting largely focuses on the number of service hours that community health

services deliver. To assess whether the CHP provides good healthcare outcomes

for Victoria’s priority populations, DHHS requires both quality‐based and

outcomes‐focused performance measures.

4.1 Conclusion


DHHS is beginning to expand its oversight of the CHP through the client

experience survey, which is a step in the right direction. While this tool provides

insight into clients’ experiences of the CHP and, by proxy, its effectiveness,

the survey requires further research and evaluation to produce optimal

results for the sector. In its current form, it has a low response rate, lacks the

methodological rigour of tools used by better practice jurisdictions—such as

New Zealand—and is long and cumbersome.

In addition, DHHS could improve its oversight of both registered and integrated

community health services by standardising its existing monitoring procedures.

DHHS uses the Funded organisation performance monitoring framework

(FOPMF) to manage registered community health services, however, this is a

relatively new tool and it is not consistently applied. DHHS’s four divisions set

their own monitoring regime for integrated community health services, which

creates further variations in performance management.

As shown in Figure 4A, DHHS’s performance management system has multiple

layers—each with varying objectives. At both the state and agency levels,

performance measuring, monitoring and reporting emphasise outputs rather

than the effectiveness and impact of care.

Figure 4A DHHS’s performance management system

Source: VAGO.

DHHS’s performance management system

Agency‐level internal reporting

Integrated communityhealth services

Registered communityhealth services

State‐level public reporting

Victorian Budget Paper 3:Service Delivery

Victorian Health Services Performance monitoring framework

Divisional Performance and

Assurance Compliance (DPAC) reporting

Funded organisation performance

monitoring framework (FOPMF)

4.2 DHHS’s performance management

system


DHHS’s public performance measures and reporting

DHHS sets public performance targets each year in the Victorian Budget

Paper 3: Service Delivery (BP3). DHHS assesses the performance of community

health care using six performance measures. As shown in Figure 4B, only two

relate to the CHP.

Figure 4B DHHS’s BP3 performance measures for community health care

Performance measure Type Relevant

Number of Better Health Channel Visits Quantity

Number of referrals made using secure electronic referral systems

Percentage of Primary Care Partnerships with reviewed and updated strategic plans

Number of service delivery hours in community health care

Percentage of agencies with an Integrated Health Promotion Plan that meets the stipulated planning requirements

Quality

Total output cost Cost

Note: The performance measure for the number of referrals relates to all referrals made to community health services.

Source: VAGO, derived from BP3.

Two performance measures relate to the CHP, however, these both assess the

quantity of care provided. DHHS lacks publicly available performance measures

that specifically evaluate the quality, impact or cost of care.

DHHS’s public reporting against performance measures

Figure 4C shows DHHS’s publicly reported performance measures and

performance for the CHP since 2014–15.

Figure 4C DHHS’s performance against targets for selected BP3 measures

2014–15 2015–16 2016–17 2017–18

Performance measure Target Actual Target Actual Target Actual Target

Number of referrals made using secure electronic referral systems

250 000 250 000 250 000 250 000 250 000 125 000(a) 250 000

Number of service delivery hours in community health care

988 000 1 055 000 988 000 1 062 000 1 000 000 1 101 000 1 015 000

(a) According to DHHS’s 2016–17 Annual Report, this result is lower than the target due to a reduction in the number of electronic referrals made through the state system, following the introduction of additional referral portals associated with Commonwealth initiatives—My Aged Care and National Disability Insurance Scheme—that redirect flow to the Commonwealth systems.

Source: VAGO based on DHHS annual reports and BP3.

4.3 State‐level performance management


The Department of Treasury and Finance’s performance management

framework outlines the mandatory requirements for presenting and assessing

performance information. According to the Department of Treasury and

Finance, departments should ‘develop performance measures that can

demonstrate service efficiency and effectiveness, and cover all major activities

of the output’.

DHHS’s measures do not comply with this mandatory requirement, as

they cannot determine whether the CHP fulfils these criteria. For example,

DHHS does not publicly explain how or why the number of service hours

changes over time. As a result, it is difficult for the public to assess whether

annual fluctuations in service hours are due to improved efficiencies,

over‐performance, or factors beyond the community health sector’s control.

Likewise, current performance measures do not analyse the CHP’s quality. While

increasing the number of service hours may suggest that the CHP can support

more clients, leading to better health outcomes, unless there is public assurance

that care is high quality and effective, the program’s achievements are

unknown. Good measures of program effectiveness and quality generally

include consultation with clients, such as analysis of client satisfaction surveys,

as well as objective measures of health improvements. Importantly, this

conforms to the sector’s overarching philosophy of person‐centred care and

provides insight into the CHP’s value.

In addition, while using the number of referrals made using secure electronic

referral systems as a measure offers some insight into the program’s efficiency,

it is largely a comment on the sector’s technical integration. As a measure, it is

somewhat redundant, because the community health sector has continuously

met DHHS’s target since its introduction in 2011–12. The target of 250 000 has

been precisely met every year except 2016–17, which raises questions regarding

the accuracy of DHHS’s reporting.

Last year, the sector only met 50 per cent of its target, however, this was due

to the introduction of new referral portals at the Commonwealth level. DHHS

noted it will reduce the 2018–19 target to 75 000 to reflect this change in

referral pathways.

DHHS’s internal performance measures and reporting

DHHS’s internal reporting for the CHP uses the same performance measure—

‘the number of service hours delivered’. Community health services receive

quarterly feedback from DHHS regarding their performance through the Funded

Agency Channel. The Funded Agency Channel is a central platform that DHHS

uses to convey information to community health services, such as procedural

changes. DHHS’s quarterly performance reports analyse the number of service

hours that community health services have delivered against their prescribed

targets. This quantitative review lacks supporting commentary and does not

promote or encourage good practice.


In addition, this performance measure does not align with the program’s

objective—to provide effective healthcare services and support to Victoria’s

priority populations. According to DHHS’s guidelines, effective care is culturally

responsive, goal directed, health promoting and evidence based. However, the

CHP’s current external performance measure is incapable of reflecting these

principles, because it lacks a person‐centred focus and cannot determine

whether care benefited the client. Likewise, as this measure fails to assess

whether the CHP targets the right people, it does not encourage community

health services to provide preferential access to Victoria’s priority populations.

Therefore, DHHS’s internal reporting cannot determine whether the program

meets its overall objective.

DHHS should consider implementing quality‐based performance measures

that assess client satisfaction following treatment, and outcomes‐focused

performance measures that assess self‐ and/or clinician‐reported changes

in health‐related outcomes, behaviours and knowledge.

In 2014–15, DHHS piloted the Victorian Community Health Indicators Project

to strengthen the program’s evidence base and foster a culture of continuous

improvement. The project aimed to deliver two complementary suites of

indicators—one focused on processes, the other on outcomes.

Process‐based indicators evaluate the clients’ administrative journey from entry

to discharge, while outcomes‐based indicators assess the impact of care. To

date, DHHS has only completed its set of process‐based indicators.

Process‐based indicators provide a particular view of service delivery, as

they test the community health services’ performance against DHHS’s

minimum requirements. Rather than outcomes, they enable community health

services to assess a different aspect of care—its implementation—which

reflects the client experience of service delivery. Process‐based indicators

represent better practice, as they conform to the sector’s key strategic

objective of person‐centred care.

DHHS’s process‐based indicators include measures such as:

the percentage of clients with multiple or complex needs who have a care

plan

the percentage of complaints acknowledged by the organisation within

two working days of receipt of the complaint.

In 2016–17, DHHS stopped collecting data against the process‐based indicators

due to feedback from the sector. While the indicators were positively received

by community health services, they imposed significant administrative burden,

as they required community health services to collect information that was

supplementary to DHHS’s standard reporting template. The sector’s diverse

range of client management systems was also an issue, as the necessary

software updates were difficult and expensive.

4.4 Action taken to address the gaps

in current performance

measures


To address this burden, DHHS is attempting to streamline the indicators’

collection as part of its Community Health Data Alignment Project. DHHS has

begun to embed the following five indicators into the CHMDS following

consultation with the sector:

timely initial needs identification

interpreter use

waiting time for highest‐priority clients

waiting time for mid‐priority clients

waiting time for lowest‐priority clients.

DHHS advises that it will continue to consult with the sector as it integrates

additional indicators into the CHMDS.

However, the absence of a complementary suite of outcomes‐based

indicators diminishes the project’s overall value, as DHHS cannot conclusively

determine whether the CHP provides effective health care to Victoria’s priority

populations. According to the Victorian Health Priorities Framework 2012–2022:

Metropolitan Health Plan, poor care coordination increases the risk of poor

outcomes for people with chronic disease. To analyse the relationship, DHHS

requires information on both processes and outcomes.

DHHS has four divisions—North, South, East and West. Each division operates

several regional offices that are located across the state. Regional offices assign

program advisors to the community health services within their jurisdiction.

Program advisors are community health services’ primary point of contact and

carry out most of DHHS’s monitoring duties.

DHHS’s performance management system differs between registered and

integrated community health services. DHHS’s oversight of registered

community health services is more rigorous than for integrated community

health services, because the integrated health services are subject to the

broader accountability systems of the hospital sector.

Agency‐level monitoring considers community health services through a holistic

lens and evaluates aspects of governance and management. It goes beyond

program‐level monitoring and assesses structural issues that may affect

performance.

Monitoring of registered community health services

Every four years, DHHS sets a service agreement with registered community

health services. This outlines the responsibilities of both parties to deliver

high‐quality services and formalises their commitment to improving Victoria’s

health and wellbeing.

Through the service agreement, DHHS allocates funding to each program and

stipulates any associated requirements. DHHS’s regional offices use the FOPMF

to assess whether community health services comply with their service

agreements.

4.5 Agency‐level performance management

across the sector


The FOPMF addresses the Minister for Health’s gazetted performance

standards, which are:

governance—the agency must be effectively governed at all times

management—the agency must be effectively managed at all times

financial management—the agency must maintain effective financial

management at all times

risk management—the agency must effectively manage the risk associated

with its business to ensure continuous, safe, responsive and efficient

services

quality accreditation and service delivery—the agency must demonstrate

that it is able to meet quality and safety standards as established by an

independent accreditation body.

The Victorian Government applies the FOPMF to various initiatives across DHHS

and the Department of Education and Training—it is not specific to community

health. FOPMF assesses foundational business elements, such as governance,

safety and workforce arrangements. Program advisors may scrutinise the

CHP’s performance as part of the community health services’ broader delivery

platform, and some explicitly identify the CHP when assessing performance risks

and issues.

DHHS rolled out the FOPMF in January 2016 alongside an 18‐month change

management process. As the FOPMF is relatively new, there are some

inconsistencies in the way DHHS applies it across community health services.

DHHS has advised us that it provides regular training opportunities to its

divisional staff to increase their familiarity with the FOPMF and its tools.

The FOPMF has two mandatory requirements—monitoring checklists and the

annual desktop review. Program advisors complete these tasks with the aid of a

risk assessment tool and Live Monitoring log. Figure 4D illustrates the elements

of the FOPMF for monitoring registered community health services.

Figure 4D Framework for monitoring registered community health services

Note: SAMS2 = Service Agreement Monitoring System.

Source: VAGO.


Funded organisation performance monitoring framework

Monitoring checklists

The FOPMF contains two checklists. These are the:

service agreement monitoring checklist—which focuses on service delivery

organisational compliance checklist—which primarily assesses the

community health services’ governance arrangements.

Program advisors must complete the FOPMF checklists annually for registered

community health services. The checklists outline DHHS’s expectations for

effective service delivery and support program advisors to conduct inquiries

in line with the minister’s gazetted performance standards.

To complete the checklists, program advisors sight evidence and determine the

agency’s level of compliance. Program advisors rate the agency’s performance

against each standardised question, and use the risk assessment tool to assign

one of the following severity ratings:

0—no issue

1—minor

2—moderate

3—major

4—critical.

How program advisors fulfil their duties is also at the discretion of their

respective divisional offices. For example, to complete the monitoring

checklists, program advisors may only require one face‐to‐face meeting with

the agency, with follow‐up conversations required to fulfil all the requirements.

DHHS does not require program advisors to conduct additional monitoring—

they must use their professional judgement.

Risk assessment tool

The risk assessment tool assists program advisors to complete the checklist and

outlines follow‐up actions based on their results. DHHS’s guidelines recommend

that regional offices perform a specific set of actions to address issues.

DHHS’s risk assessment tool lacks consistent definitions for program advisors.

It describes each severity rating—or particular level of risk—using a series of

hypothetical scenarios. For example, a ‘minor disruption’ in the provision of

services results in a ‘minor’ severity rating, whereas a ‘modest disruption’

equates to a ‘moderate’ severity rating. In the absence of quantifiable

thresholds, program advisors must subjectively judge the difference between

minor and modest. This leads to inconsistent performance management across

DHHS’s divisions.


As shown in Figure 4E, DHHS’s West division created the performance escalation

framework (PEF) to overcome these issues and support consistent application of

the FOPMF across its agencies. DHHS’s central office is aware of this document,

however, DHHS does not know at this stage whether it will implement it across

the state.

Figure 4E West division’s performance escalation framework

The West division’s PEF helps the division’s staff to assess and remediate issues in a consistent manner. It assigns a point‐scale to three major risk areas or ‘categories,’ which program advisors use to determine an agency’s PEF score.

If a program’s PEF score surpasses the thresholds for the major risk categories—levels 1, 2 and 3—the division intensifies its monitoring. As shown below, the seniority of the team member responsible for ongoing monitoring activities increases with the agency’s PEF score.

Category 1 compares a program’s reported activity against its allocated target. This is an important indicator, as under‐ or over‐performance may point to other issues, such as data entry errors or service delivery failures. Category 2 refers to the number of reportable periods that a program has failed to achieve its target. This enables staff to identify systemic issues, as sustained under‐performance may require organisational changes. Finally, Category 3—‘other identified risk factors’—assesses the number of ‘minor’ or ‘moderate’ issues logged in the agency’s Live Monitoring log. This strengthens existing monitoring procedures, as the FOPMF only escalates ‘major’ or ‘critical’ issues to the director or manager, and lacks thorough guidance for the remediation of other problems. The West division’s increased oversight encourages timely risk mitigation, which may prevent smaller issues from escalating.

As shown in the figure below, program advisors also weight a program’s PEF score according to its financial value. This assists staff to prioritise their duties across a range of agencies and programs.

The PEF enables the West division’s program advisors to discharge their monitoring duties in a standardised manner, which creates greater consistency and ensures that the right people address issues at the right time.

Source: VAGO based on documentation from DHHS’s West division.


Live Monitoring log

The Live Monitoring log is a key component of the Service Agreement

Monitoring System, DHHS’s primary management platform. According to

DHHS’s guidelines, program advisors must use the log to catalogue any issues

and manage their agencies’ remediation plans.

DHHS’s guidelines also advise program advisors to promote their agencies’

‘success stories’ through the Live Monitoring log to encourage greater

recognition of their innovative projects.

DHHS’s divisions used the Live Monitoring log inconsistently. For example,

the North division identified two ‘moderate’ performance risks at one

community health service in 2016–17. The program advisor flagged these issues

in the appropriate checklist but failed to enter them into the log. This limits the

North division’s ability to identify trends, as it lacks a centralised history of the

community health service’s performance.

In contrast, the North division’s checklists identified four issues at another

community health service. The program advisor appropriately catalogued these

issues in the Live Monitoring log alongside the health service’s remediating

plans. This complies with DHHS’s guidelines and represents good practice, as

the division has oversight of the actions undertaken to improve performance.

We heard from both divisional offices and community health services that some

program advisors prefer not to register issues in the Live Monitoring log, as each

entry generates multiple emails, which clutters their inboxes. This practice

causes confusion for the affected community health services, as DHHS’s

behaviour and expectations differ from program advisor to program advisor.

We did not see any evidence of DHHS promoting innovative practices through

the Live Monitoring log. Instead, most program advisors flagged good practice

in the annual desktop review. It is unknown how cataloguing ‘success stories’

on either platform provides community health services with greater recognition,

as their performance information is neither visible to their peers nor promoted

within DHHS.


Desktop review

Program advisors collate an agency’s annual monitoring portfolio—including the

completed checklists, Live Monitoring log and any additional communication—

to produce a desktop review. Desktop reviews aim to identify any risks or trends

and inform the agency’s overall monitoring‐level. If the desktop review

identifies significant issues, DHHS may intervene or initiate a service review. This

involves a full‐scale investigation into the agency’s activities and performance.

There is a degree of duplication between the content of the annual desktop

review and the monitoring checklists. As these tools provide point‐in‐time

analysis, their effectiveness is reduced if they are completed within a short time

frame.

For example, DHHS finalised the 2016–17 desktop reviews for North Richmond

Community Health and cohealth within two months of completing the

checklists. The relevant offices, therefore, discharged their minimum monitoring

duties within a short window. This may limit DHHS’s identification of emerging

risks, as DHHS’s annual scrutiny covered a single quarter of the year. The West

division addresses this potentially limited view through additional meetings

with cohealth, however, the North division did not provide us with evidence of

continued engagement with North Richmond Community Health.

South division’s supplementary monitoring tools

As shown in Figure 4F, the South division has created two supplementary tools

to help it identify activity‐based issues—the ‘traffic light’ performance matrix

and issues log. These give the division oversight beyond the FOPMF’s minimum

monitoring requirements and enable program advisors to track trends over

various years. The tools also facilitate continued engagement with health

services, as they create a centralised service history that assists program

advisors to efficiently monitor agencies. DHHS’s central office was not aware

of these supplementary monitoring tools and should consider implementing

them across the state.


Figure 4F South division’s ‘traffic light’ performance matrix and issues log

The South division’s ‘traffic light’ performance matrix enables program advisors to evaluate the sector’s performance from two different perspectives. As shown below, the vertical axis of the ‘traffic light’ matrix lists the South division’s funded agencies, while the horizontal axis outlines the range of programs managed in the division. Each row highlights the performance of a single funded agency at the program level, while each column evaluates the program’s total output. This allows the divisional office to identify whether performance issues are present across an entire program, or isolated to a particular agency.

Source: DHHS’s South division.

The ‘traffic light’ matrix allows program advisors to identify performance risks at a glance and pinpoint emerging trends. It also tallies the ‘unused dollars’ for each funded agency. This functions as an additional performance measure for the division, as underspending may indicate other performance issues, such as workforce shortages, data entry errors or service delivery failures.

The South division also has an issues log for each funded agency. The issues log tracks an agency’s quarterly performance across various programs—including the CHP—for a range of years. It compares the number of service hours delivered against the agencies’ prescribed target, and includes a space for qualitative remarks.

While the ‘comments’ section does not explain every aspect of under‐ or over‐performance, it provides valuable information regarding any issues. For example, in 2016–17, Latrobe Community Health Service delivered 0 per cent of its Healthy Mothers, Healthy Babies Program target for quarters one, two and three and only 1 per cent in quarter four. The ‘comments’ section explains that Latrobe Community Health Service was unable to recruit for this position until the following financial year. This example demonstrates that the South division has continuous oversight.



Monitoring of integrated community health services

In comparison to registered community health services, integrated community

health services experience less formal monitoring from DHHS. This is because

they are subject to the broader accountability systems of the hospital

performance team, which operates from DHHS’s central office. Each year, DHHS

negotiates Statements of Priorities with Victoria’s public health services. The

Statement of Priorities is a legislative requirement that outlines the health

services’ key deliverables and performance targets, and assigns an annual

budget to each major activity. DHHS uses the Victorian Health Services

Performance monitoring framework (the framework) to determine whether

agencies comply with their Statements of Priorities.

DHHS’s central office and regionally based rural health teams are responsible

for monitoring the performance of Victoria’s public health services, public

hospitals and multipurpose services. To oversee these health services, DHHS

conducts quarterly meetings with each agency. Quarterly performance meetings

assess the health service’s performance against its Statement of Priorities and

generally focus on acute and sub‐acute activities, such as the elective surgery

waiting list.

Victorian Health Services Performance monitoring framework

While DHHS’s central office monitors the overall health service, its divisions

are responsible for assessing health services’ delivery of the CHP. The CHP,

therefore, lacks standing representation at health services’ quarterly meetings

with DHHS’s central office.

DHHS’s divisional directors and regional program advisors do not conduct

equivalent quarterly meetings with community health services. Instead,

each office decides on individual monitoring schedules for its agencies. This

diminishes DHHS’s oversight of the CHP, as program advisors lack a standardised

framework for continuous engagement. While some program advisors

communicate with their agencies on a regular basis, others are less frequent.

As the framework’s primary focus is acute and sub‐acute performance, it has

minimal relevance for integrated community health services. For example, none

of its 98 indicators directly scrutinise the provision of community health care.

As a result, DHHS’s framework cannot assess whether integrated community

health services deliver timely, safe or effective care to priority populations.

DHHS’s engagement with integrated community health services

As DHHS’s divisions do not have a formal monitoring framework specific to

integrated community health services, there is no guidance regarding the

frequency or scope of monitoring activities. As a result, DHHS’s divisions take

different approaches to monitoring across integrated community health

services.


Monitoring of metropolitan and regional health services

The South division does not hold quarterly performance meetings with Monash

Health or Peninsula Health. Instead, DHHS has ‘annual update’ meetings with

both agencies. The South division supplements this oversight through informal

correspondence, such as email chains. In contrast, the North division holds

quarterly performance meetings with Bendigo Health.

In 2016–17, Bendigo Health’s internal restructure affected the North division’s

monitoring schedule, and only two out of four meetings occurred. During this

period, Bendigo Health’s board and its community health service experienced

various leadership changes. DHHS’s Victorian Health Services Performance

monitoring framework explicitly identifies ‘recent turnover’ as an underlying risk

factor, as it may cause significant administrative issues. We saw no evidence of

this issue being discussed at the broader health service’s meetings with DHHS’s

central office.

While quarterly meetings are not mandatory for community health services,

DHHS should have monitored Bendigo Health more closely during this period to

ensure that this disruption did not impact the provision of care. DHHS advised

us that monitoring via phone conversations occurred during this time. However,

a lack of formal documentation creates issues if program advisors change

duties, and may be difficult to verify.

Monitoring of small rural health services and multipurpose health services

In addition to divisional monitoring, DHHS’s Rural Health team conducts

quarterly performance meetings at East Wimmera Health Service and Orbost

Regional Health. The meeting minutes demonstrate that DHHS has regular

contact with both agencies and strong oversight of emerging risks.

Although community health is not a standing agenda item, East Wimmera

Health Service’s director of clinical and community health and Orbost Regional

Health’s director of community health attend their agencies’ respective

meetings. This means that there is a consistent communication channel

between DHHS and the community health service.

DHHS publishes performance information from East Wimmera Health Service

and Orbost Regional Health in the Small Rural Health Services’ Monitor (the

monitor) on a quarterly basis. The monitor benchmarks agencies in accordance

with DHHS’s key performance domains. As a result, it is largely concerned with

clinical governance and delivery of acute services. While the monitor reports

the number of service hours delivered in community health, it lacks contextual

information—such as the effect of workforce shortages or the introduction of

innovative programs—which diminishes its relevance to the broader sector.


Both registered and integrated community health services are subject to

DHHS’s Divisional Performance Assurance Compliance (DPAC) process. The

DPAC process, conducted biannually, aims to encourage continuous quality

improvement through regular and transparent discussions with agencies.

According to divisional staff, the DPAC process is a key accountability process

for integrated community health services because—unlike their registered

counterparts—they lack a formalised monitoring framework.

The DPAC process requires divisional directors to inform DHHS’s executive board

of their respective community health services’ performance. Its purpose is to

assure the board that divisional staff appropriately discharge their duties as

relationship managers and performance monitors. While the DPAC process

primarily focuses on outputs, directors also discuss key issues within their

division, highlight areas for improvement and promote better practice.

The DPAC process is beneficial, as it ensures that community health services’

performance is visible to the upper levels of DHHS management. However, it

should function as an additional layer of scrutiny rather than as the sole

monitoring mechanism for integrated community health services.

Complete, consistent and accurate data is essential for performance

management, as it provides DHHS with a good analytical baseline. Each of

DHHS’s funded programs is subject to different reporting obligations and time

lines. For example, DHHS requires quarterly submission of CHP data for the

CHMDS and annual submission for data on health promotional activities. DHHS

regularly updates its reporting guidelines to reflect any changes to the CHMDS

and allows community health services to resubmit any missing or corrected files

twice yearly.

The health system’s devolved governance model means that community health

services deliver funded programs with minimal interference from DHHS. As a

result, DHHS does not provide community health services with a universal

client management system to input their various datasets. Instead, community

health services collect their data using a range of different products, each with

different capabilities. Certain funded programs, such as Dental Health, mandate

the use of a particular client management system. This means that community

health services generally operate multiple client management systems to

support their various programs. The Primary Care Partnerships Service

Coordination survey undertaken in 2015 reported that there were 15 client

management systems in use across the sector.

4.6 The Divisional Performance

Assurance and Compliance process

4.7 Data reporting for performance

management


This wide variety of client management systems—coupled with DHHS’s different

reporting obligations for each dataset—do not support community health

services to provide integrated care. Behind the scenes, community health

services must disaggregate the different components of their ‘wrap around’

service delivery model to fulfil DHHS’s varied reporting requirements, which is

a time‐consuming and cumbersome process. As different client management

systems support different funded programs, it is difficult for community health

services to obtain a clear image of their client’s journey through the system. For

example, a client’s dental health treatment plan is stored in a separate software

application to his or her allied health appointments. This also leads to

duplicated effort for practitioners, as they must input clients’ profiles across

multiple systems.

In 2017, DHHS commenced the Community Health Data Alignment Project

to reduce the reporting burden on community health services. DHHS

commissioned specialists to undertake a review of three major datasets—

Community Health, Dental Health, and Alcohol and other Drug Treatment

Services—and make recommendations. The review found that DHHS uses

inconsistent terminology across its datasets, which contain a mixture of

redundant, irrelevant and complex data elements. It also found that some of

DHHS’s existing validation rules—or data cleansing methods—are out of date

or insufficient.

The review also flagged DHHS’s minimal feedback as a key issue for the

community health sector. DHHS mandates the collection of various data

elements, but fails to translate the data into meaningful information. For

community health services, this decreases the relevance of complete, consistent

and accurate data entry. The review further notes that data entry errors at

community health services may be the result of limited training, software

limitations and resource constraints.

To address this, DHHS is considering the annual release of de‐identified data to

enable benchmarking among community health services.

Since late 2016–17, DHHS has made various changes to the CHMDS, as outlined

in its most recent Community Health Program Data Submission Guidelines. This

includes the removal of redundant data elements, the addition of vital concepts

and language alignments. DHHS has also conducted multiple workshops with

the sector to identify concerns and communicate any progress. Overall, DHHS’s

Community Health Data Alignment Project is a step in the right direction.

DHHS has accepted all of the review’s recommendations, which demonstrates

its commitment to reducing the reporting burden for community health

services. The project is scheduled for completion in mid‐2018–19 and includes a

post‐implementation review to assess its impact.


In addition to its performance management system, DHHS has guidance and

tools for community health services to encourage high‐quality service delivery.

DHHS defines high‐quality care as safe, effective and person centred. This

means that community health services must reduce the risk of avoidable

harm, deliver timely, appropriate and integrated care, and encourage clients

to voice their opinions throughout their clinical journey. Continuous quality

improvement is also a foundational principle of the CHP and one of DHHS’s key

underlying policies.

We assessed whether DHHS’s guidance to community health services aligns

with best practice principles for high‐quality service delivery—such as

accreditation and consumer engagement—and fulfils the CHP’s objective of

providing effective healthcare to Victoria’s priority populations.

Accreditation

DHHS expects community health services to meet basic minimum requirements

for safe, effective and person‐centred care. These requirements are formalised

in accreditation cycles and DHHS’s guidelines.

Accreditation is pivotal to DHHS’s quality assurance framework. It involves an

external body formally reviewing an agency’s policies, procedures and practices.

Accrediting bodies will generally conduct top‐down evaluations of an agency’s

outcomes, workforce retention rates, infrastructure and clinical governance

arrangements. Accreditation is a legislative requirement for both integrated and

registered community health services.

Accreditation aims to optimise safety and mitigate risks for both community

health services and the Victorian public. DHHS oversees the state’s accreditation

register and may intervene at community health services to address any issues.

Community health services undergo accreditation assessments for both

Commonwealth‐ and state‐funded programs.

Community health services’ accreditation

As community health services deliver a range of programs, they often require

multiple accreditation awards. We heard anecdotally from community health

services that the accreditation cycle is resource intensive and creates a

widespread administrative burden. According to the audited community health

services, each accreditor requires similar documentation in a slightly different

format, which leads to duplicated effort from allied health practitioners,

doctors, nurses and support staff. Community health services recognise the

importance and value of accreditation, but note that it increases their already

heavy workloads.

4.8 High‐quality service delivery


As an example, Figure 4G shows the various accreditations held by cohealth as

at 2016–17.

Figure 4G cohealth’s current accreditation awards

Accreditation award Accredited areas Next due

Quality Improvement Council

Whole organisation July 2018

Royal Australian College of General Practitioners

Medical practices Various throughout 2018

National Safety and Quality Health Standards

Oral health July 2018

DHHS’s standards Integrated family services

Family Violence Support Services

Indigo Care Coordination

July 2018

Home Care Standards Essendon Adult Day Centre

August 2020

Source: VAGO based on cohealth’s Annual Report 2016–17.

In July 2018, cohealth will be reassessed for three of the above standards. This

means that cohealth will be subject to multiple accreditation assessments

within a relatively short time frame, which may reduce the time its clinical staff

can spend with clients.

Community Health Streamlining Accreditation Project

In 2017, DHHS commenced the Community Health Streamlining Accreditation

Project to identify options that reduce the regulatory load for community

health services. It engaged consultants to produce a sector accreditation profile,

which confirmed the burden experienced by community health services.

The consultants identified that, on average, community health services hold

accreditation against five mandatory standards. Accreditation burdens

community health services through membership fees, onsite assessments,

staff exertion and unnecessary duplication. The report recommended various

changes, such as reducing repetition through greater coordination of standards,

streamlining assessments at the Commonwealth level, and supporting service

delivery models that improve health services’ use of resources. Importantly,

the report emphasised that DHHS should proactively engage with other

stakeholders—such as the Commonwealth—to encourage system‐wide

change and innovation.


To address these issues, DHHS has committed to reviewing the duplication

between its internal standards and other regulatory mechanisms, such as the

FOPMF. It will also advocate to the Commonwealth and support community

health services to strengthen their governance capabilities. DHHS has amended

its 2017–18 Policy and funding guidelines to note that if a community health

service is already accredited for governance and management under a

recognised standard, it is not required to gain this accreditation again for its

primary and community health funded services. This demonstrates DHHS’s

commitment to understanding and addressing the sector’s concerns.

Service Coordination Practice Manual

DHHS’s Service Coordination Practice Manual (the manual) helps community

health services align their intake and assessment procedures with optimal

practice principles, such as person‐centred care. The manual aims to improve

the client experience by ensuring the following:

People should receive the right care regardless of their entry point into the

system—this is known as the ‘no wrong door’ policy.

Independent providers—such as community health services—should

develop transparent and consistent care pathways that are clear and

understandable to clients. This requires effective information sharing

between agencies so that clients receive seamless and integrated care.

Practitioners should conduct effective assessments that identify their

clients’ needs at the earliest instance. This reduces the chance of further

clinical deterioration.

The manual also outlines DHHS’s expectations for the key stages of service

coordination—initial contact, initial needs assessment and care planning. It

assigns responsible staff members to these stages and describes each stage in

detail, including good practice indicators and ideal client outcomes. This gives

community health services a standard to emulate. The manual provides the

foundations for continuous quality improvement and high‐quality care.

In 2013 and 2015, DHHS conducted a statewide survey to assess whether

community health services comply with the manual’s best practice principles

for care planning, information sharing and use of the Service Coordination Tool

Templates. The survey specifically assessed whether community health services

complied with indicators from the Primary Care Partnership’s Program Logic

2013–17 strategy, which align with the manual’s key concepts.

Overall, the 2015 survey shows that some service coordination occurs, however,

there is room for improvement. For example, of the state’s 339 respondents

across DHHS’s eight regions, 62 per cent have developed a local agreement

that supports shared care planning, while only 46 per cent have gone on to

implement the plan. The survey provides DHHS with valuable information

regarding the manual’s use at community health services and encourages

benchmarking across the divisions. However, there is no evidence that

DHHS used the survey results to improve service delivery, or facilitated

information‐sharing forums to assist community health services to learn,

innovate and adapt their approaches.


Beyond the survey, DHHS has minimal oversight of the manual’s integration in

community health services. The South division, however, uses its benchmarking

report as an additional quality assurance mechanism. As shown in Figure 4H,

the division’s report enables it to pinpoint areas for improvement and remind

community health services of their obligations to deliver high‐quality care.

DHHS’s central office is aware of this report, however, it is unknown whether it

will be implemented across the state.

Figure 4H Traralgon office’s (South division) benchmarking report

DHHS’s Traralgon office uses a benchmarking report to assess community health services’ local performance across a range of different parameters. Benchmarking is a popular performance management tool, as it encourages cross‐agency learning, the identification of service delivery gaps, and the implementation of best practice. To create the report, DHHS’s Traralgon office consolidates information from the CHMDS and produces a series of graphs. The graphs reflect the performance of eight local community health services across a three‐year period and explore various funded activities, such as allied health, nursing, care coordination and INI.

According to the Traralgon office, the report provides a supportive approach to continuous improvement, as it encourages self‐reflection and collegial behaviour. The audited community health services value the report as a catalyst for internal and external discussions, however, some advised that they would benefit from more qualitative commentary, such as the sharing of local innovations.

In addition to its benchmarking role, the report enables DHHS to reiterate the importance of key principles, such as integrated care and robust data collection. For example, of the eight community health services assessed, only four collect information regarding INI—despite all community health services reporting that INI is an essential element of their service delivery models. Through the benchmarking report, the Traralgon office emphasises the importance of INI’s role in securing holistic, multidisciplinary care. This may encourage community health services to reassess DHHS’s good practice indicators—as outlined in the Service Coordination Practice Manual—and collect the relevant INI data going forwards.

Overall, the report represents good practice, as it promotes introspective analysis across the region. The Southern metropolitan area has recently adopted Traralgon’s template and is receiving similar feedback.

Source: VAGO.

Engaging with clients

Engaging with their clients demonstrates community health services’

commitment to high quality, person‐centred care, as it values the individual’s

needs and opinions. Effective client engagement may also reduce waste, lower

costs and enhance clients’ outcomes. DHHS engages with the clients of

community health services through feedback tools, such as patient experience

surveys. It also requires each community health service to publish an annual

‘quality account’ to increase their public accountability.


Victorian Healthcare Experience Survey—Community Health

DHHS extended its annual VHES to the community health sector in late 2016.

The survey aims to enhance person‐centred care by engaging local communities

in improving the delivery of health services. It supplements the limited insight

provided by DHHS’s existing performance measures, and increases community

health services’ accountability.

DHHS distributed 50 000 surveys across 85 agencies and achieved an overall

response rate of 15.2 per cent. The survey was voluntary and anonymous, and

targeted adult clients across a three‐month window. It contained 66 questions—

63 were multiple choice and three were free text. At the end of the survey,

DHHS published the state’s results through a secure online portal and imposed a

minimum response threshold to ensure statistical integrity. As a result, agencies

with a response rate of less than 30 surveys were unable to view their individual

results, as small samples convey limited insight.

The survey evaluated different aspects of service delivery, such as access,

staff attitudes, the agency’s built environment, and the effectiveness of

care planning. While community health services often conduct their

own consultative exercises, DHHS’s survey promotes continuous quality

improvement, as it provides a standardised platform for benchmarking and

cross‐agency learnings. DHHS translated the survey into various languages to

maximise inclusion, and some community health services assisted their clients

to complete the questionnaire on site.

While the survey supports DHHS’s commitment to person‐centred care, it has

various issues. For example, the survey is lengthy and does not consider the

literacy levels of Victoria’s priority populations. In designing the survey, DHHS

met with consumer representatives from both Manningham Community Health

Service and Caulfield Community Health Service as part of a broader advisory

group, however, both representatives did not attend all three developmental

workshops. Sixteen clients across Melbourne and Bendigo later piloted the draft

survey and this informed its revisions. Therefore, DHHS’s engagement with

consumer representatives was low. In contrast, New Zealand trialled its

equivalent survey with 10 focus groups containing 88 people during the first

stage of its testing process, and later conducted numerous face‐to‐face

interviews with clients.

DHHS intends for community health services to publicise certain aspects of the

survey’s results in their upcoming quality accounts, however, due to the

survey’s low response rate, it is unknown whether it will accurately portray

community health services’ performance.

Detailed client engagement is pivotal, as it enables governments to produce

effective tools that adequately meet the needs of their target audience. This

is emphasised by Orbost Regional Health’s Consumer Reference Group, which

vets and approves the agency’s external communication prior to its release. All

publicly available documents receive the reference group’s ‘consumer tick of

approval for readability’, which represents better practice as it validates the

agency’s commitment to person‐centred care.


Quality accounts

DHHS mandates the publication of quality accounts. Quality accounts

emphasise transparency and enable community health services to publicise

their commitment to safe, effective and person‐centred care. They are produced

annually and aim to provide stakeholders with clear and accessible information

regarding an agency’s performance, with a particular emphasis on processes

and outcomes.

DHHS outlines mandatory standards for agencies through its Quality Account

Reporting Guidelines. These guidelines stress the importance of ‘listening to

patients’ and demonstrating ‘continuous improvement’. According to DHHS,

community health services must publicise their methods of seeking and

responding to client feedback, list their accreditation status, describe a quality

improvement process that targets the program’s priority populations, and

demonstrate their commitment to continuity of care.

In addition, public health services—such as hospitals—report against a range of

measures, including the results of the acute sector’s patient experience survey

and the prevalence of healthcare‐associated infections.

Quality accounts provide public health services with a platform to explain their

performance, and outline their improvement. In contrast, community health

services lack standardised performance measures that enable the public to

objectively evaluate the services’ progress on an annual basis, and assess their

level of improvement. The information presented within quality accounts is

largely at the community health services’ discretion and is generally qualitative

in nature.

While quality accounts supplement the information provided in BP3, the

absence of specific performance measures means that the public can neither

benchmark services, nor track their progress over the years.


Appendix A Audit Act 1994 section 16—submissions and comments

We have consulted with DHHS, Bendigo Health, East Wimmera Health Service,

Monash Health, Peninsula Health, Bendigo Community Health Service, cohealth,

Gippsland Lakes Community Health, Latrobe Community Health Service, North

Richmond Community Health and Orbost Regional Health, and we considered

their views when reaching our audit conclusions. As required by section 16(3) of

the Audit Act 1994, we gave a draft copy of this report to those agencies and

asked for their submissions or comments. We also provided a copy of the

report to the Department of Premier and Cabinet.

Responsibility for the accuracy, fairness and balance of those comments rests

solely with the agency head.

Responses were received as follows:

DHHS .................................................................................................................... 62

cohealth ............................................................................................................... 66


RESPONSE provided by the Secretary, DHHS


RESPONSE provided by the Secretary, DHHS—continued


RESPONSE provided by the Chief Executive, cohealth


RESPONSE provided by the Chief Executive, cohealth—continued

Auditor‐General’s reports tabled during 2017–18

Report title Date tabled

V/Line Passenger Services (2017–18:1) August 2017

Internal Audit Performance (2017–18:2) August 2017

Effectively Planning for Population Growth (2017–18:3) August 2017

Victorian Public Hospital Operating Theatre Efficiency (2017–18:4) October 2017

Auditor‐General’s Report on the Annual Financial Report of the State

of Victoria, 2016–17 (2017–18:5)

November 2017

Results of 2016–17 Audits: Water Entities (2017–18:6) November 2017

Results of 2016–17 Audits: Public Hospitals (2017–18:7) November 2017

Results of 2016–17 Audits: Local Government (2017–18:8) November 2017

ICT Disaster Recovery Planning (2017–18:9) November 2017

Managing the Level Crossing Removal Program (2017–18:10) December 2017

Improving Victoria’s Air Quality (2017–18:11) March 2018

Local Government and Economic Development (2017–18:12) March 2018

Managing Surplus Government Land (2017–18:13) March 2018

Protecting Victoria’s Coastal Assets (2017–18:14) March 2018

Safety and Cost Effectiveness of Private Prisons (2017–18:15) March 2018

Fraud and Corruption Control (2017–18:16) March 2018

Maintaining the Mental Health of Child Protection Practitioners

(2017–18:17)

May 2018

Assessing Benefits from the Regional Rail Link Project (2017–18:18) May 2018

Results of 2017 Audits: Technical and Further Education Institutes

(2017–18:19)

May 2018

Results of 2017 Audits: Universities (2017–18:20) May 2018

All reports are available for download in PDF and HTML format on our website

www.audit.vic.gov.au

Victorian Auditor‐General’s Office

Level 31, 35 Collins Street

Melbourne Vic 3000

AUSTRALIA

Phone +61 3 8601 7000

Email [email protected]

community health program · 2018-06-05 · victorian auditor‐general’s report community health...

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